Thank you for contacting Fournier Insurance Solutions.
The information collected from this questionnaire will help us
prepare a homeowner's proposal for you.
This will take approximately 10 minutes to complete.
How did you hear about us?

Your name: *

Date of Birth: *

2nd Insured's name: *

If there is no additional insured, please input "none."
2nd Insured's Date Of Birth:

Day time contact phone number(s): *

Location Address: *

Mailing address, if different from location address:

How would you rate the service that our agency provides?

5 being the best

Years at Current Residence: *

If you have been at your residents less than 3 years, please provide prior address(es):

Your employer and occupation: *

Education Level: *

Marital Status: *

Do you currently have home owner's insurance? *

Current Insurance Company: *

Is your current coverage being non-renewed or cancelled, why? *

How long have you had your current coverage? *

Current Deductible: *

Dwelling Coverage? *

Liability Coverage? *

Special Personal Property? *

Do you currently have coverage on any of the following? *

Are you interested in obtaining coverage on any of the following? *

Have you had any claims in the last 5 years? *

Please list the date, type, and amount paid on the claim(s): *

The following questions pertain to information about your home.

Number of Stories: *

Year built: *

Is your home: *

Square footage: *

Foundation Type: *

Do you have a basement? *

What percentage is your basement finished/unfinished? *

Type of Roofing: *

Type of siding: *

Year roof was last updated or replaced: *

Year plumbing updated or replaced: *

Your electric box contains: *

Year electrical was updated or replaced: *

Auxiliary heat: *

Number of hearths: *

Number of Chimneys: *

Heat Type: *

Do you have a solar unit? *

Do you have central a burglar alarm? *

Do you have a central fire alarm? *

Do your doors have deadbolts? *

Do you have smoke detectors? *

Do you have a fire extinguisher? *

Distance to fire Hydrant:

Distance to Fire Station:

Number of Bathrooms and size: *

Example:  2-full, 1-1/2,  1-3/4
Do you have a pool? *

Do you have a hot tub? *

Please list number of decks or porches and their square footage. *

Do you have a car port? *

Do you have a garage? *

Number of cars? *

Do you own any animals? *

We like animals too! What type/breed of animals do you own? *

Please include breed and how many.
Do any of your animals have a bite history? *

Any Extra Features? *

Please select all that apply.

Are there any businesses being operated in the home?  If Yes, please explain. *

Mortgagee name: *

If you are unsure or do not have the information with you, please put "unknown."
Mortgagee address:

If you are unsure or do not have the information with you, please put "unknown"
Loan Number:

If you are unsure or do not have the information with you, please put "unknown"
Have you done any remodeling in the last year? *

Do you serve on any non-profit boards? *

Do you belong to a homeowner's association? *

Do you have any of the following:

Please select all that apply.

Do you own any of the following?

Please select all that apply.

Do you rent the home or other structures out to others? *

Do you provide home day care? *

Do you maintain an office in your home or provide private lessons? *

Do you maintain any samples or  articles for sale on your premises? *

Do you own any property used in your trade, business, or profession? *

Do you have a personal property inventory? *

Thank you {{answer_7762692}} for taking the time
to complete this questionnaire for a home policy proposal.
One of our agents will be contacting you soon.
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